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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005195
Report Date: 03/29/2022
Date Signed: 03/29/2022 05:39:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/29/2022 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:STETSON COURT LIVINGFACILITY NUMBER:
397005195
ADMINISTRATOR:GAOIRAN, CHRISTIANFACILITY TYPE:
740
ADDRESS:3913 STETSON COURTTELEPHONE:
(408) 876-9445
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
03/29/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Geline Artuz and GAOIRAN, CHRISTIAN TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to continue the annual inspection from 3/28/22. LPA met with Geline Artuz and later joined byGAOIRAN, CHRISTIAN

LPA was able to open document sent to the email address provided to verify staff information as well as the residents information for R1 and R2. During the inspection today the facility sent over information for R1 that is not dated or signed. The information for R2 is not complete and is missing the signature for the physician on the LIC 602 Physician's report. This information was cleared by Administrator.

S1 is not associated to this facility. This was verified by the department's Office tech on 3/29/2022.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed during this inspection. Civil penalties assessed. The 809 D page is attached to the report dated 3/28/2022 as this is a continued inspection from that date.

Exit interview held with Staff.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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